Delaware is one of the smallest states in the Union both in terms of geography and population, but it is one of the most densely populated states and has been a ready adopter of healthcare reform. The state’s health insurance exchange, Choose Health Delaware, continues to feature just one carrier offering coverage to state residents, Highmark Blue Cross Blue Shield Delaware. After being awarded a 3 percent rate increase for 2019, Highmark saw a rate decrease of -19 percent for 2020, and was awarded an average 1 percent decrease for 2021. Delaware is in the process of implementing a model that will move the healthcare industry away from fee-for-service and focus on quality care and population health management. To that end, the state introduced a 3.8 percent spending benchmark as a target for 2019, with the goal of ultimately getting expenditures lowered to 3 percent on a consistent basis. In addition, the state announced a series of value-based payment reform grants to providers to facilitate data integration and improve coordination through alternative payment models. the state is in the midst of a major overhaul of its Medicaid program, with the goal an increased focus on quality care. This could prove beneficial to pharmaceutical companies as patient drug adherence is likely to receive greater scrutiny. Medicare Advantage traditionally not been a strong sector in Delaware.